What is the management of infectious mononucleosis (mono)?

Management of Infectious Mononucleosis (Mono)

Infectious mononucleosis management is primarily supportive care, with corticosteroids reserved only for severe complications such as impending airway obstruction. 1, 2

Clinical Presentation and Diagnosis

• Classic triad: fever, tonsillar pharyngitis, and lymphadenopathy 1

• Other common findings:

  • Fatigue (may persist for several months)
  • Periorbital/palpebral edema (in approximately 1/3 of patients)
  • Splenomegaly (in approximately 50% of cases)
  • Hepatomegaly (in approximately 10% of cases)
  • Skin rash (in 10-45% of cases) - typically maculopapular
  • Atypical lymphocytosis (>10% of total lymphocyte count)

• Diagnostic tests:

  • Heterophile antibody test (Monospot) - most widely used
  • EBV-specific antibody testing when Monospot is negative but clinical suspicion remains high

Treatment Algorithm

1. Supportive Care (First-Line Management)

• Adequate hydration
• Analgesics for pain control (acetaminophen, NSAIDs)
• Antipyretics for fever
• Rest as tolerated (patient's energy level should guide activity) 3

2. Activity Restrictions

• Avoid contact sports or strenuous exercise for at least 8 weeks or while splenomegaly is present 1
• This is crucial to prevent splenic rupture (occurs in 0.1-0.5% of cases and is potentially life-threatening) 1

3. Medications to AVOID in Routine Cases

• Corticosteroids: Not recommended for routine treatment 3, 2

  • Reserve only for severe complications:
    • Impending airway obstruction
    • Severe pharyngeal edema
    • Autoimmune complications
    • Hematological complications

• Acyclovir: Not recommended for routine treatment 3

  • No proven benefit in uncomplicated infectious mononucleosis

• Antihistamines: Not recommended for routine treatment 3

4. Special Considerations

Immunocompromised Patients

• Higher risk for complications and prolonged course
• In severe primary EBV infection in immunocompromised patients, consider:
  • Reduction or discontinuation of immunomodulator therapy if possible 4
  • Ganciclovir or foscarnet may be considered in severe cases despite limited evidence 4

Monitoring for Complications

• Monitor for signs of splenic rupture (left upper quadrant pain, Kehr's sign)
• Watch for neurological complications (rare)
• Be alert for secondary bacterial infections, especially in patients on steroids 5

Important Caveats and Pitfalls

1. Avoid unnecessary corticosteroids: Prolonged steroid use in uncomplicated cases can lead to serious complications including sepsis and secondary infections 5, 2

2. False-negative Monospot tests: Common early in the course of infection; consider EBV-specific antibody testing if clinical suspicion is high 3

3. Duration of symptoms: Inform patients that fatigue may persist for several months after acute infection has resolved 3

4. Risk of splenic rupture: Ensure patients understand the importance of avoiding contact sports and heavy lifting during recovery 1

5. Differential diagnosis: Consider other infections that can mimic mono (cytomegalovirus, toxoplasmosis, streptococcal infection) in patients with negative heterophile antibody tests 3

The management of infectious mononucleosis remains primarily supportive, focusing on symptom relief and prevention of complications. While most cases resolve without specific intervention, careful monitoring and appropriate activity restrictions are essential to prevent rare but serious complications such as splenic rupture.